Every finding on record at Brentwood Health Center

Based on clinical record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors, for 1 of 1 resident reviewed for buspirone (a medication prescribed to reduce anxiety) administration, Resident ID #1.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 7/15/2026 alleged that Resident ID #1 was administered triple the dose of his/her ordered buspirone as s/he should have been receiving 7.5 milligrams (mg).Review of an undated facility policy titled Medication Administration Safety Program (MASP) - Safety Guidelines states in part, .It is the policy of this facility that resident shall receive medications in a safe and timely manner and in accordance with established regulations and guidelines.the physician's order must be verified before the medication is given.According to Lippincott Nursing Procedures, ninth edition, page 743, states in part, .to prevent medication errors, nurses must.adhere to the 'five rights' of medication administration: identify the right patient.select the right medication; administer the right dose; administer the medication at the right time; and administer the medication by the right route.Record review revealed Resident ID #1 was admitted to the facility in January of 2026 with a diagnosis including, but not limited to, anxiety.Record review of the hospital discharge document titled, Continuity of Care Adult Discharge dated 1/20/2026 revealed the following medication order:-Buspirone 5 mg tablet, take 1.5 tablets twice a day (7.5 mg).Review of the January 2026 Medication Administration Record (MAR) revealed the above-mentioned physician's order was transcribed as buspirone 5 mg tablet, take three 1/2 tabs = 7.5 mg twice a day.Review of a photocopy taken on 1/25/2026 of the blister pack medication card dispensed by the pharmacy on 1/20/2026, revealed buspirone 15 mg tablets 1/2 tablets, with the instructions to give one 1/2 tab twice a day = 7.5 mg. Further review revealed a sticker placed on the card by the pharmacy stating, Directions Changed Refer to Doctor's Order Book. Additional review of the blister pack revealed 14 1/2 tablets were removed, indicating those tablets were administered.Record review of a provider note dated 1/25/2026 states in part, .nurse called to report that the patient appears to have been receiving overdose of Buspirone.patient was ordered to get buspirone 15 mg 0.5 tab 7.5 mg PO [by mouth] BID [twice a day], however, the order was entered as give three half tabs PO BID in essence patient has been receiving 22.5 mg BID.During a surveyor interview on 8/20/2026 at approximately 11:10 AM with Licensed Practical Nurse, Staff A, she revealed that the pharmacy had delivered a different dose of the buspirone with different administration instructions on 1/20/2026 when compared with the physician's order dated 1/20/2026. She further revealed that she was made aware of the discrepancy on 1/24/2026 and created a new order to reconcile the blister pack and the medication order; however, she entered the order incorrectly.During a surveyor interview on 8/20/2026 at 1:15 PM with Certified Medication Technician (CMT) Staff B, she revealed that she administers medications according to the physician's order in the electronic medication record and does not reconcile the order with the order instructions on the blister pack medication card. She further revealed that she makes sure she is giving the correct medication; however, does not reconcile the dosage with the physician's order in the electronic MAR. Additionally, she acknowledged that she gave Resident ID #1 three 1/2 15 mg tablets of buspirone, equaling 22.5 mg, on the morning of 1/21/2026 and on 1/22/2026. Record review of the January 2026 MAR revealed CMT, Staff B, administered Resident ID #1 his/her buspirone on the morning of 1/21/2026 and on 1/22/2026.During a surveyor interview on 8/20/2026 at 1:20 PM with Advanced Practical Registered Nurse (APRN), she revealed that she would expect staff to reconcile the dispensed medication that is being administered with the physician's order in the electronic medical record prior to administration to ensure it's the correct dose. She further revealed that she would've expected the order to be modified correctly when the discrepancy was identified. Additionally, she would've expected Resident ID #1 to receive 7.5 mg of buspirone twice daily as ordered.During a surveyor interview on 8/20/2026 at approximately 4:00 PM with the Director of Nursing Services, she was unable to provide evidence that Resident ID #1 was administered the correct dose of buspirone from 1/20/2026 through 1/25/2026.

Based on surveyor observation, clinical record review, and staff interviews, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent pressure ulcers for 1 of 1 resident reviewed, Resident ID #3. Specifically, the resident was left on a bedpan for an undetermined length of time, resulting in prolonged, unrelieved pressure and the worsening of an existing pressure ulcer, as well as the development of a new pressure ulcer. Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 4/6/2026, states in part, .This patient.was left on the bedpan and was injured.Record review revealed the resident was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, an unstageable pressure ulcer (an unstageable pressure ulcer is a full thickness wound which is caused by prolonged pressure over a bony prominence, where the depth and extent of the tissue damage cannot be determined because the wound bed is obscured by dead tissue, slough or eschar) of the sacrum (triangular bone at the base of the spine that connects the spinal column to the pelvis).Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 out of 15 indicating s/he had moderate cognitive impairment. It further revealed that the resident is dependent on staff for toileting and rolling from side to side.Record review of the wound care physician's documentation dated 3/17/2026, revealed that the resident had a pressure ulcer to his/her sacrum measuring 4 centimeters (cm) by 4.2 cm by 0.1 cm along with a surgical incision to the spine which measured 43 cm. During a surveyor interview on 4/21/2026 at 2:07 PM with Registered Nurse, Staff A, she revealed that the resident was admitted to the facility with a pressure area to his/her sacrum. She further revealed that the day the worsened pressure area was discovered the Nursing Assistant (NA), Staff B, told her that she found the resident lying on a bed pan, but she was unable to tell her how long the resident had been lying on the bed pan. Additionally, she indicated that the resident was noted with a new large nonblanchable area (skin redness that does not fade when pressure is applied, indicating tissue damage or compromised blood flow), which later developed into an open wound.Record review of a written statement by Nursing Assistant, Staff, B, revealed that she arrived for her shift at 7:20 AM on 3/21/2026, and that she went to offer care to the resident at 9:30 AM, 10:20 AM, and 11:30 AM but the resident declined. The statement further indicated that while she was providing care to the resident at 2:00 PM, she took the sheet off the resident, rolled him/her and realized that the resident was lying on a bedpan. Additionally, Staff B, indicated that at no time during that shift had anyone told her that the resident was assisted onto the bedpan.Record review of a progress note written by the Nurse Practitioner, Staff C on 3/23/2026 at 9:45 AM revealed in part, .seen today for a newly identified area of skin breakdown over the coccyx area. On examination there is a crescent shaped area along the coccygeal region (the anatomical area surrounding the coccyx) measuring approximately 8 cm in length and 2 cm in width. The area shows purple nonblanchable discoloration with a loss of skin integrity. Onset is new since prior documented skin assessment.Findings are concerning for a pressure related injury.Record review of the wound care physician's documentation dated 3/24/2026 states in part .Incident occurred where [resident] was on bedpan extended period of time: worsened unstageable sacrum wound and caused a [pressure ulcer] on [right] thigh. The documentation further revealed that the pressure ulcer to the sacrum now measured 10.5 cm by 11 cm by 0.1 cm, which was an increase from the wound measurements on 3/17/2026. It further revealed that the resident had a new stage 3 pressure ulcer (a stage 3 pressure ulcer is a full thickness skin injury that extends into the subcutaneous fat but does not expose muscle, tendon or bone) to the right thigh measuring 1.5 cm by 3.5 cm x 0.1 cm.During a surveyor interview on 4/21/2026 at 11:00AM with the wound care Physician, she revealed that when she assessed the wound after she was notified of an incident with the bed pan, there was a crescent shaped wound that extended from the initial sacral wound. She further indicated that this crescent shaped wound appeared to follow the line of a bed pan.During a surveyor observation of the resident's wounds on 4/21/2026 at 11:45 AM in the presence of the wound care Physician's Assistant, the sacrum pressure ulcer was measured as 11.2 cm by 8.5 cm by 1 cm. The right thigh pressure ulcer was measured as 1.1 cm by 2.6 cm by 0.1 cm.During a surveyor interview on 4/21/2026 at 2:57 PM with the Director of Nursing Services, she acknowledged that she could not determine the length of time that the resident was left lying on the bed pan. Additionally, she acknowledged that the resident's pressure areas had deteriorated after the resident was found lying on the bed pan for an undetermined length of time.The facility's failure to ensure the timely removal of Resident ID #3, who is dependent on staff for assistance with toileting and has an existing pressure wound, from a bedpan and the failure to provide appropriate monitoring and repositioning, resulted in the resident being left on a bedpan for an undetermined period of time. This failure resulted in actual harm, as evidenced by the worsening of an existing pressure ulcer and the development of a new pressure ulcer. Cross reference F609

Based on clinical record review and staff interview, the facility failed to ensure that all alleged violations involving neglect are reported immediately, but not later than 2 hours to the State Survey Agency in accordance with State law for 1 of 1 resident reviewed related to being left on a bedpan for an undetermined length of time, which resulted in worsening of and the development of a new pressure ulcer, Resident ID #3.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 4/6/2026, states in part, .This patient.was left on the bedpan and was injured.Review of the facility policy titled. Abuse prohibition states in part, .Neglect = failure to provide goods and/or services necessary to avoid physical harm.Any instance of actual or suspected.neglect.including injuries of unknown origins including bruises, skin tears, or lacerations must be reported immediately to the DNS (Director of Nursing Services).The Department of Health.will be contacted of allegations of.neglect.within 2 hours of the allegation if the events that led to the allegation.result in serious bodily injury.It is the responsibility of the Nursing Home Administrator to.submit the report of the allegations and the results of the internal investigation to the department of Health within 5 working days of the original filing.Record review revealed the resident was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, an unstageable pressure ulcer (an unstageable pressure ulcer is a full thickness wound which is caused by prolonged pressure over a bony prominence, where the depth and extent of the tissue damage cannot be determined because the wound bed is obscured by dead tissue, slough or eschar) of the sacrum (a triangular bone at the base of the spine that connects the spinal column to the pelvis).Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 of 15 indicating s/he had moderate cognitive impairment. It further revealed that the resident is dependent on staff for toileting and rolling from side to side.Record review of the wound care physician's documentation dated 3/17/2026, revealed that the resident had a pressure ulcer to his/her sacrum measuring 4 centimeters (cm) by 4.2 cm by 0.1 cm along with a surgical incision to the spine which measured 43 cm. Record review of a progress note written by the Nurse Practitioner, Staff C, on 3/23/2026 at 9:45 AM revealed in part, .seen today for a newly identified area of skin breakdown over the coccyx area. On examination there is a crescent shaped area along the coccygeal region (the anatomical area surrounding the coccyx) measuring approximately 8 cm in length and 2 cm in width. The area shows purple nonblanchable (skin redness that does not fade when pressure is applied, indicating tissue damage or compromised blood flow) discoloration with a loss of skin integrity.Onset is new since prior documented skin assessment. Findings are concerning for a pressure related injury.Record review of wound care physician documentation dated 3/24/2026 states in part, .Incident occurred where [patient] was on bedpan extended period of time: worsened unstageable sacrum wound and caused a [pressure ulcer] on [right] thigh. The documentation further revealed that the pressure ulcer to the sacrum measured 10.5 cm by 11 cm by 0.1 cm and that the resident had a new stage 3 pressure ulcer (a stage 3 pressure ulcer is a full thickness skin injury that extends into the subcutaneous fat but does not expose muscle, tendon or bone) to the right thigh measuring 1.5 cm by 3.5 cm x 0.1 cm.During a surveyor interview on 4/21/2026 at 2:57 PM with the Director of Nursing Services, she acknowledged that the worsened pressure area was due to the resident being left on the bed pan for an undetermined length of time. She was unable to provide evidence that the incident involving neglect, related to leaving this resident on the bedpan for an undetermined amount of time, resulting in his/her pressure areas worsening, was reported immediately, but not later than 2 hours to the State Survey Agency in accordance with State law.Cross reference F686

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives necessary respiratory care and services in accordance with professional standards of practice relative to a Bilevel Positive Airway Pressure device (BiPAP-a type of ventilator that assists with breathing and delivers two levels of air pressure, a higher pressure for inhalation and lower pressure for exhalation) for 1 of 1 resident reviewed, Resident ID #1.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients .Record review revealed Resident ID #1 was readmitted to the facility on [DATE] with a diagnosis including, but not limited to, chronic respiratory failure with hypoxia (a serious condition characterized by the inability to effectively exchange carbon dioxide and oxygen).Record review of the resident's hospital discharge documents revealed a physician discharge instruction dated 11/3/2025 that states in part, .will require BiPAP during naps and nightly .Record review revealed a physician's order dated 11/3/2025 to administer BiPAP nightly.Record review of the November 2025 Treatment Administration Record failed to reveal evidence that the resident received his/her BIPAP on 11/3, 11/4, 11/5 and 11/6/2025. Record review revealed a progress note dated 11/6/2025 authored by Nurse Practitioner, Staff A, indicated the resident experienced a recent hospitalization due to respiratory distress and was discharged back to the nursing home with instructions to use a BiPAP. Since readmission to the facility, they have been waiting for the BiPAP machine to be adjusted. The nursing staff reported that patient continued with a worsening condition, including shortness of breath, acute on chronic respiratory failure, and cough related to the fact that the patient still hasn't been able to use the BiPAP, as ordered.Additional record review of a progress note dated 11/7/2025 authored by Nurse Practitioner, Staff B, indicated there was a concern that the resident's BiPAP machine is still pending arrival. During a surveyor interview on 11/19/2025 at 2:13 PM with Nurse Practitioner, Staff B, she revealed it would be her expectation that the resident would have received his/her BiPAP, as ordered.During a surveyor interview on 11/19/2025 at approximately 3:00 PM with the Director of Nursing Services, she revealed it would be her expectation that the BiPAP would be obtained by the facility to administer to the resident within one day of readmission. Additionally, she was unable to provide evidence that the BiPAP was administered as ordered until 11/7/2025, indicating the facility failed to provide this treatment for three days.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety relative to the main kitchen and for one of two kitchenettes.Findings are as follows:1. The Rhode Island Food Code 2022 Edition 4-601.11 states in part, .nonfood contact surfaces of equipment shall be kept from an accumulation of dust, dirt, food residue and other debris.During surveyor observations of the main kitchen on 7/22/2025 at 8:50 AM and 7/24/2025 at 10:57 AM revealed the following:-the walls behind the dish machine, stove and worktables were observed to have an accumulation of food spills/splatters -Formica topped food carts were observed to have chips in the corners of the carts -the gaskets of the ice chest had an accumulation of a black substance2. The Rhode Island Food Code 2022 Edition 4-602.11 states in part, .equipment of the food contact surfaces.shall be cleaned at any time during the operation when contamination may have occurred.During a surveyor observation on 7/22/2025 at 8:50 AM of the main kitchen, the delivery chute of the ice machine had a pink substance along the upper rim of the chute.3. The Rhode Island Food Code 2022 Edition 3-302.12 states in part, .except for containers that can be readily and unmistakably recognized, working containers holding food that are removed from the original packages shall be identified with the common name of the food.During a surveyor observation on 7/22/2025 at 8:50 AM of the main kitchen, one reach in refrigerator unit revealed the following:-One package of a white colored meat product that was cut up into cubes without a label-1/4-inch pan that contained a red substance was without a label4. The Rhode Island Food Code 2022 Edition 4-904.13 states in part, .tableware that is preset shall be protected from contamination by being wrapped or covered.During surveyor observations of the lunch meal service on 7/22/2025, 7/23/2025 and 7/24/2025 the individual lunch trays were observed on an open cart while being transported on the elevators and along the hallways with preset silverware that were not covered or wrapped.5. Record review of a document from The United States Department of Agriculture recommends dry food storage temperatures between 50 F (Fahrenheit) and 70 F for quality and for the control of bacterial growth.During a surveyor observation on 7/25/2025 at 10:57 AM, the ambient temperature of the dry storage room read 85 F.6. Record review of a facility document titled, Brentwood Nursing Home Refrigerator Dating Guidelines states in part, .if a product is opened, then a 3-day expiration must be placed on the product.During a surveyor observation on 7/22/2025 at 11:30 AM of the first-floor dining room refrigerator, an opened container of a product with a manufacturer's label of Market Basket Hearty Chicken Noodle soup had a date of 7/16/2025.During a surveyor interview on 7/25/2025 at 11:40 AM with the Director of Food Service he acknowledged the walls, the ice machine and the gaskets on the ice chest needed to be cleaned. Additionally, he acknowledged that the Formica food carts needed to be replaced, the temperature in the dry storage room was too hot, the labels were missing on unidentifiable food items, the chicken soup exceeded the facility's 3-day policy, and that the silverware on meal trays should have been covered.

Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain a sanitary and comfortable environment relative to food trays being left in the hallways on one of two nursing units after meal hours with partially consumed meals. Findings are as follows:During surveyor observations of the first-floor nursing unit, the following was revealed:7/22/2025 at 11:30 AM, four food trays uncovered from the breakfast meal with partially consumed food 7/22/2025 at 3:45 PM, two food trays uncovered from the lunch meal with partially consumed food 7/23/2025 at 11:30 AM, four trays uncovered from the breakfast meal with partially consumed food 7/24/2025 11:00 AM, three trays uncovered from the breakfast meal with partially consumed food7/24/2025 at 4:00 PM, four trays uncovered from the lunch meal with partially consumed foodDuring a surveyor interview on 7/25/2025 at 11:40 AM with the Director of Food Service, he acknowledged that the food trucks were left uncovered in the hallway after meal hours and contained partially consumed food on the trays.

Based on record review and staff interview, it has been determined that the facility failed to ensure that staff were competent to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as the facility staff were unable to identify a change in condition, administer oxygen in the setting of hypoxia (low blood oxygen level), document accurately, and administering medications as ordered for one of four residents reviewed, Resident ID #8. Findings are as follows:1.Record review revealed Resident #8 was re-admitted to the facility in June of 2025 with a diagnosis including, but not limited to, sepsis (a systemic infection that can lead to tissue damage, organ failure and possible death). Record review revealed a physician's order dated 1/28/2025 to administer oxygen at 1-4 liters per minute via nasal cannula (a medical device that provides supplemental oxygen therapy to people who have lower oxygen levels) as needed for shortness of breath or hypoxia (low blood oxygen level).Record review of a nursing progress note dated 7/20/2025 at 7:52 AM states in part, 0600 upon am rounds, resident was found by cna [Certified Nursing Assistant] in bed full of watery stool from head to toe. Resident was washed up and bed changed. Resident seems to be agitated and thrashing around in bed. VS [vital signs] obtained, and temp [temperature] was 98.4 [F], Resp [respirations] 24 [normal range 12-16], BP [blood pressure] 98/58 [normal blood pressure is 120/80], not a perfect bp due to resident thrashing around. [oxygen saturation, SpO2] @ [at] 77% [a normal SpO2 level ranges between 95% to 100%; a reading below 95% increases the risk of damage to your tissues and organs] During a surveyor interview on 7/24/2025 at 10:07 AM with Licensed Practical Nurse (LPN), Staff A, he revealed that he went in to administer a medication to Resident ID #8 a little after 5:00 AM. Resident ID #8 was observed to be uncomfortable, restless and kicking [his/her] arms and lifting [his/her] hips off of the bed. Additionally, Staff A, revealed that he was able to obtain pulse oximetry readings (used to monitor arterial oxygen saturation non-invasively) of 79% and 84%. When questioned by the surveyor why oxygen was not administered to the resident per the physician's order when the resident had SpO2 readings of 79% and 84% indicating that s/he was hypoxic, Staff A was unable to answer and acknowledged that the oxygen was not administered as ordered. When questioned what intervention was put in place for the resident related to the abnormal SpO2 readings and the appearance of discomfort, restlessness and the inability to obtain vital signs, Staff A revealed that he raised the resident's head of the bed to 90 degrees. Furthermore, Staff A acknowledged that he was unable to get the tablet working to contact the on-call provider related to the resident's change in condition. When questioned by the surveyor what other interventions were attempted, he revealed that he continued passing medications to the other residents.2. Record review revealed a physician's order dated 6/11/2025 for Synthroid (a medication prescribed to treat hypothyroidism) 88 micrograms once daily in the morning.Record review of the July 2025 Medication Administration Record revealed that the Synthroid was signed as administered on 7/20/2025 at 5:26 AM.During a surveyor interview on 7/24/2025 at 10:07 AM with Staff A, he revealed that he pre-poured the Synthroid medication for Resident ID #8, signed it off in the electronic medical record prior to administering the medication, and indicated that he was unaware that he was not supposed to sign it off before administering it to the resident. 3. Record review revealed a progress note dated 7/20/2025 at 1:34 AM, which states, Resident alert w/confusion at baseline. Call light for assistance with transfers and ambulation. Resident verbalizes understanding but has poor follow through. Neuro signs [observable physical indicators that can help diagnose neurological disorders] are stable. AROM [active range of motions refers to unassisted range of movement of a joint] to all extremities. Resident was compliant with diet orders. Resident slept throughout the night with no c/o [complain of] pain or discomfort.During an interview with Staff A on 7/24/2025 at 10:07 AM, he revealed that he has a USB (universal serial bus) drive with a pre-written notes that he copies information from to write his nursing progress notes. Staff A acknowledged that he did not assess the resident's range of motion and neurological status, and that he inaccurately copied that information from his USB drive.During a surveyor interview on 7/24/2025 at 11:30 AM with the Director Nursing Services, she was unable to provide evidence that Staff A was competent in assessing, providing accurate documentation of medication administration and nursing progress notes, despite receiving competencies. Cross reference F 580, F 658, F 684 and F 690

Based on record review and staff interview, it has been determined that the facility failed to provide the appropriate treatment and services for 1 of 1 resident reviewed for constipation, Resident ID #8.Findings are as follows:Review of the facility policy titled, Bowel function management, states in part, It is the policy of this facility to manage each resident's bowel function in order to promote regular, voluntary, controlled bowel evacuation of normal consistency. Normal bowel function involves passage of soft, formed stools in adequate volumes without straining .Every resident's bowel function is to be monitored every day on every shift.The charge nurse is responsible to monitor the resident's bowel activity daily.Interventions to promote adequate bowel function: 1. Determine the resident's bowel function by regular review of the bowel documentation .Assess the success of the .interventions .Record review revealed the resident was readmitted to the facility in June of 2025 with a diagnosis including, but not limited to, sepsis (a systemic infection that can cause tissue damage, organ failure, and possible death), constipation.Review of the bowel records failed to reveal evidence that the resident had a bowel movement from 7/9/2025 through 7/13/2025, indicating that s/he did not have a bowel movement for 5 days. Record review failed to reveal evidence that the physician was notified of the resident's lack of bowel movements over the 5-day time period.During a surveyor interview on 7/25/2025 at 1:52 PM with Nurse Practitioner, Staff G, she indicated that she would expect to be notified when a resident went without a bowel movement for three days for further interventions.During a surveyor interview on 7/25/2025 at 2:20 PM with the Director of Nursing Services, she revealed that it would be her expectation that nursing staff would contact the provider if a resident went without a bowel movement for three days for further interventions.Cross reference F 580, F 658, F 684 and F 726.

Based on record review and staff interview, it has been determined that the facility failed to provide the necessary treatment and care in accordance with professional standards of practice relative to obtaining orthostatic vital signs per a physician's order, identifying a change in a resident's condition and physician notification, for 1 of 1 resident reviewed for hospitalization, Resident ID #8. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients. According to Jensen's Fourth Edition, Nursing Health Assessment, page 118 states, Orthostatic vital signs are measured in patients to assess for a drop in BP [blood pressure].with position changes .Some medications can have the adverse effect causing orthostatic hypotension.Assess BP.with the patient [lying], sitting, and standing.waiting 1-2 minutes after each position change to assess the readings.Drop in SBP [systolic blood pressure] of 15 mmHg [millimeters of mercury] or greater, drop of DBP [diastolic blood pressure] of 10 mmHg or greater.indicates orthostatic hypotension. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 7/20/2025 states in part, .Incident of unknown origin.facility informed.about an injury of fractured ribs and lacerated spleen.Family and MD [medical doctor] all aware. Investigation to be completed. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/25/2025 alleges in part, that the resident arrived at the hospital after a suspected unwitnessed fall. S/he had bruising on the left flank, a grade 4 splenic laceration (classified as a severe injury involving significant vascular injury and active bleeding), and displaced fractures of the left 10th and 11th ribs. Record review revealed the resident was re-admitted to the facility in June of 2025 with a diagnosis including, but not limited to, sepsis (a systemic infection that can lead to tissue damage, organ failure and even death). Record review of the care plan last revised on 7/21/2025 with a focus area indicating the resident has a history of falling and is at risk of future falls with interventions including, but not limited to, orthostatic vital sign monitoring (measurements of blood pressure and heart rate taken while a patient is in different positions, primarily to assess for orthostatic hypotension and other cardiovascular issues) due to the use of Seroquel (an antipsychotic medication) and update the physician or nurse practitioner (NP) with changes as needed. 1.Record review of the progress notes revealed that the resident sustained falls on the following dates: -7/13/2025 found kneeling in front of the sink -7/13/2025 resident noted on the floor in the middle of his/her room -7/14/2025 found on the floor of his/her bathroom -7/14/2025 resident was found kneeling next to his/her bed Record review revealed a physician's order to monitor the resident's orthostatic blood pressure daily for three days dated 7/15/2025 with a discontinue date of 7/17/2025, then weekly for four weeks. Review of the July 2025 Medication Administration Record failed to reveal evidence that orthostatic blood pressures were obtained, as ordered. During a surveyor interview on 7/24/2025 at 11:30 AM with the Director Nursing Services, she was unable to provide evidence that the orthostatic blood pressures were obtained for Resident ID #8. Cross reference F 580, F 690, F 726.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 4 residents reviewed related to oxygen utilization, for 1 of 1 resident reviewed relative to orthostatic blood pressure (measurements of blood pressure taken while a patient is in different positions), Resident ID #8, and for 3 of 7 residents reviewed relative to weight discrepancies, Resident ID #s 16, 29, and 75.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.1. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 7/20/2025 states in part, .Incident of unknown origin.facility informed.about an injury of fractured ribs and lacerated spleen.Family and MD [medical doctor] all aware. Investigation to be completed.Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/25/2025 alleges in part, that the resident arrived at the hospital after a suspected unwitnessed fall. S/he had bruising on left flank, a grade 4 splenic laceration (classified as a severe injury involving significant vascular injury and active bleeding), and displaced fractures of the left 10th and 11th ribs.Record review revealed that Resident ID #8 was re-admitted to the facility in June of 2025 with a diagnosis including, but not limited to, sepsis (a systemic infection that can to tissue damage, organ failure and possible death). a. Record review revealed a physician's order dated 1/28/2025 to administer oxygen 1 to 4 liters per minute via nasal cannula (a medical device that provides supplemental oxygen therapy to people who have lower oxygen levels) as needed. During a surveyor interview on 7/24/2025 at 10:07 AM with Licensed Practical Nurse (LPN) Staff A, he revealed that he went in to administer a medication to Resident ID #8 a little after 5:00 AM. Resident ID #8 was observed to be uncomfortable, restless and kicking [his/her] arms and lifting [his/her] hips off of the bed. Additionally, Staff A, revealed that he was able to obtain pulse oximetry readings (used to monitor arterial oxygen saturation non-invasively) of 79% and 84% (a normal oxygen saturation [SpO2] level range is between 95% to 100%; a reading below 95% increases the risk of damage to your tissues and organs) for the resident. When questioned by the surveyor why oxygen was not administered to the resident when the resident had an SpO2 readings of 79% and 84% indicating that s/he was hypoxic (low blood oxygen level), Staff A was unable to answer and acknowledged that the oxygen was not administered as ordered.b. According to Jensen's Fourth Edition, Nursing Health Assessment, page 118 states, Orthostatic vital signs are measured in patients to assess for a drop in BP [blood pressure].with position changes .Some medications can have the adverse effect causing orthostatic hypotension.Assess BP.with the patient [lying], sitting, and standing.waiting 1-2 minutes after each position change to assess the readings.Drop in SBP [systolic blood pressure] of 15 mmHg [millimeters of mercury] or greater, drop of DBP [diastolic blood pressure] of 10 mmHg or greater.indicates orthostatic hypotension.Record review revealed a physician's order dated 7/15/2025 to obtain orthostatic blood pressures once a day for 3 days then weekly for four weeks.Review of the July 2025 Medication Administration Record from 7/15/2025 to 7/20/2025 failed to reveal evidence that orthostatic blood pressures were obtained.During a surveyor interview on 7/24/2025 at approximately 2:10 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that the physician's orders were followed for Resident ID #8 for the utilization of oxygen when needed and that orthostatic blood pressures were obtained. 2. Review of the facility policy titled, Weight Loss/Gain Protocol . revealed the following:-The resident will be weighed on the day of admission-The resident will then be weighed weekly for three weeks and after the first four weeks of admission, the frequency of weights will then be decided by the interdisciplinary team.-A significant weight discrepancy is defined as:A weight change of 3 pounds or more in one weekA loss/gain of 5% or greater in one month.-When a significant weight loss/gain is noted, a reweigh shall be done within 48 hours of the initial weight.-If the reweigh is accurate and there has been a significant weight loss/gain, nursing must notify the physician, dietician, DNS, and the resident representative.a. Record review revealed that Resident ID #16 was admitted to the facility in July of 2025 with a diagnosis including, but not limited to, Type II diabetes mellitus.Record review of the resident's weights revealed the following:-7/14/2025 188.5 lbs. (pounds) -7/20/2025 155.8 lbs. (32.7 lbs. difference with no evidence of reweigh)Further record review failed to reveal evidence that a reweigh was completed until it was brought to the facility's attention by the surveyor on 7/24/2025. During a surveyor interview on 7/24/2025 at 1:14 PM with Licensed Practical Nurse (LPN), Staff E, she indicated that the residents are weighed on admission but if there is an admission weight discrepancy, a reweigh must be obtained. She acknowledged that there was no reweigh on 7/20/2025, and that she would have expected the staff to have reweighed the resident on that day or the next day.During a surveyor interview on 7/25/2025 at approximately 1:00 PM with the Dietitian, she acknowledged that she noted the 32.7 lbs. weight discrepancy and had requested a reweigh to be obtained for Resident ID #16. However, she acknowledged the weight was not obtained until it was brought to the facility's attention by the surveyor on 7/24/2025.b. Record review revealed Resident ID #29 was readmitted to the facility in July of 2025 with a diagnosis including, but not limited to, urinary tract infection.Review of the resident's weights revealed the following:-7/10/2025 weight 207 lbs.-7/15/2025 weight 215.5 lbs. (8.5 lbs. difference with no evidence of reweigh)-7/22/2025 weight 211.8 lbs. (3.7 lbs. difference with no evidence of reweigh)During a surveyor interview on 7/25/2025 at 11:02 AM with LPN, Staff F, she acknowledged that she entered the 215.5 lbs. weight on 7/15/2025 but did not reweigh the resident.c. Record review revealed Resident ID #75 was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, abnormal weight loss.Review of the resident's weights revealed the following:-6/17/2025 weight 193.6 lbs. -6/24/2025 weight 197.4 lbs. (3.8 lbs. discrepancy with no evidence of reweigh)-7/8/2025 - weight 197.5 lbs.-7/22/2025 - weight 190.6 lbs. (6.9 lbs. discrepancy with no evidence of reweigh)During a surveyor interview on 7/25/2025 at 12:44 PM with the Dietitian, she acknowledged the weight discrepancies but indicated she was not notified by nursing staff. She indicated that the resident should have been reweighed after the 190.6 lbs. weight documented on 7/22/2025.During a surveyor interview on 7/25/2025 at 11:19 AM and 2:09 PM with the Director of Nursing Services, she indicated that it would be her expectation that when a weight discrepancy is identified, a reweigh will be obtained.Cross reference F 580, F 684, F 690 and F 726.

Based on record review and staff interview, it has been determined that the facility failed to immediately inform the resident's physician of his/her change of condition, which resulted in the transfer of the resident to an acute care hospital for 1 of 4 residents reviewed, Resident ID #8.Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 7/20/2025 states in part, .Incident of unknown origin.facility informed.about an injury of fractured ribs and lacerated spleen.Family and MD [medical doctor] all aware. Investigation to be completed.Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/25/2025 alleges in part, that the resident arrived at the hospital after a suspected unwitnessed fall. S/he had bruising on left flank, a grade 4 splenic laceration (classified as a severe injury involving significant vascular injury and active bleeding), and displaced fractures of the left 10th and 11th ribs.Record review of a facility policy dated 10/17/2023 titled Resident Change in Condition states in part, .Changes in condition require assessment by the Nurse and notification to the MD (both to be done timely). Timely depends upon the level/severity of the change and the Nurse should use professional assessment and judgment to make that decision. Timely is certainly no later than the shift of the change.Record review revealed the resident was re-admitted to the facility in June of 2025 with a diagnosis including, but not limited to, sepsis (a systemic infection that can to tissue damage, organ failure and possible death). Record review of the resident's progress note dated 7/20/2025 at 7:52 AM authored by third shift, Licensed Practical Nurse (LPN), Staff A, revealed that the resident was found by the nursing assistant in bed full of watery stool from head to toe at 6:00 AM and his/her vital signs were obtained which revealed, respirations of 24 (normal range 12-16), pulse oximetry of 77% (a normal oxygen saturation level ranges between 95% to 100%; a low reading below 95% increases the risk of damage to your tissues and organs), and a blood pressure of 98/58 (normal blood pressure is 120/80).Further record review of the progress notes dated 7/20/2025 at 7:30 AM authored by first shift, Registered Nurse (RN), Staff B, revealed that upon his arrival, the resident was found to be moaning and not responding. The resident was placed on 2 liters of oxygen via nasal cannula (a medical device that provides supplemental oxygen therapy to people who have lower oxygen levels) due to an oxygen saturation of 77%, emergency medical services arrived and the resident was transported to the emergency department.During a surveyor interview on 7/24/2025 at 10:07 AM with Staff A, he revealed that at approximately 5:00 AM, a nursing assistant notified him that the resident was found in bed with a large amount of watery stools. He further indicated that he later went in to administer a medication to the resident a little after 5:00 AM, and the resident was observed to be uncomfortable, restless and kicking [his/her] arms and lifting [his/her] hips off of the bed. Additionally, he revealed that he asked RN, Staff C, to assist him with the resident around 5:30 AM - 5:45 AM. He further revealed that Staff C instructed him to call the provider, but he was unable to do so, as the tablet did not work. During a surveyor interview on 7/24/2025 at approximately 11:00 AM with Staff C, she revealed that Staff A came down to get her to look at [Resident ID #8] around 6:00 AM because s/he was restless and kept moving his/her arms and lifting his/her knees up. Additionally, she revealed that she was unaware that Staff A did not notify the on-call provider.During a surveyor interview on 7/24/2025 at 11:10 AM with the resident's medical doctor, Staff D, he revealed that he would expect the staff to call him if they were unable to contact the on-call provider related to the resident's change in condition.During a surveyor interview on 7/25/2025 at 11:35 AM with the Director Nursing Services and the Assistant Director of Nursing Services, they were unable to provide evidence that the resident's provider was immediately notified of his/her change in condition until the day shift nurse Staff B arrived for his shift at 7:00 AM, which was approximately two hours after the initial change in condition was identified. Record review of an RI EMS [Rhode Island emergency medical services] Patient care report revealed that dispatch was notified at 7:34 AM and the unit was dispatched to the facility at 7:36 AM. Additionally, the report revealed upon EMS arrival that the resident was lying in bed unresponsive with left and right-side weakness. Cross reference F 658, F 684, F 690, F 726.

Based on record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for 4 of 4 residents reviewed relative to pain medication administration, Resident ID #s 1, 2, 3, and 4. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/14/2025 alleged that Resident ID #1 was not receiving his/her pain medications from staff even though s/he complained of an 8 out 10 pain level. 1. Record review revealed Resident ID #1 was admitted to the facility in December of 2021 with diagnoses including, but are not limited to, left lower limb cellulitis (a bacterial skin infection), acute respiratory failure and emphysema (a chronic lung disease that damage the lungs' air sacs making the breathing difficult). Record review of the resident's significant change status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating an intact cognition. Review of the resident's care plan revised on 2/18/2025 revealed the resident has chronic pain with interventions to administer pain medications, monitor and record its effectiveness, document the pain's location, frequency, intensity, alleviating and aggravating factors. Further record review of the care plan dated 2/19/2025 revealed s/he is receiving Hospice care with interventions to monitor and assess for pain and ensure a comfortable end of life. Review of the Resident ID #1's medical record failed to reveal evidence that the above-mentioned interventions related to his/her pain were being implemented. 2. Record review revealed Resident ID #2 was readmitted to the facility in December of 2022 with diagnoses including, but not limited to, stage 2 pressure ulcer (injury to the skin resulting from prolonged pressure on the skin) of right and left heels and chronic pain syndrome (a condition characterized by persistent pain that lasts longer than expected with change in skin temperature, color and sweating). Record review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15, indicating severe cognitive impairment. Review of the resident's care plan revised on 2/19/2024 revealed the resident complains of chronic pain with interventions to administer the pain medications, evaluate, monitor, record and report the effectiveness and any adverse side effects. Additional review revealed an intervention to monitor and record any complaints of pain, its location, frequency, intensity, its effect on function, the alleviating and aggravating factors. Review of the Resident ID #2's medical record failed to reveal evidence that the above-mentioned interventions related to his/her pain were being implemented. 3. Record review revealed Resident ID #3 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, adult failure to thrive (a condition characterized by a significant decline in physical and emotional well-being, leading to an inability to maintain a healthy and functional life). Record review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15 indicating, severe cognition impairment. Review of the care plan dated 2/19/2025 revealed the resident receives Hospice care related to adult failure to thrive with interventions to monitor and assess for pain. Review of Resident ID #3's medical record failed to reveal evidence that the above-mentioned interventions related to his/her pain were being implemented. 4. Record review revealed Resident ID #4 was admitted to the facility in November of 2020 with a diagnosis including, but not limited to, depression. Record review of the resident's MDS assessment dated [DATE] revealed a BIMS score of 6 out of 15, indicating severe impaired cognition. Review of the care plan dated 4/22/2024 revealed the resident has chronic pain related to neuropathy with interventions to anticipate the resident's need for pain relief and to identify, record, and treat the resident's condition. Review of Resident ID #4's medical record failed to reveal evidence that the above-mentioned interventions related to his/her pain were being implemented. During a surveyor interview on 4/15/2025 at approximately 1:00 PM, with Registered Nurse, Staff B, she acknowledged that they do not document the residents' pain even though it is outlined in the care plan. Additionally, Staff B indicated they only ask the resident about their pain. During a surveyor interview on 4/15/2025 at 1:04 PM with the Assistant Director of Nursing (ADNS), she indicated that she would expect the staff to follow the care plans. Cross reference F 658

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality related to following physician's orders for 1 of 4 residents reviewed for pain and anxiety medication administration, and for 1 of 3 residents reviewed for the use of an air mattress, Resident ID #1. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Review of a facility policy titled Medication Administration Safety Program states in part, .It is the policy of this facility that residents shall receive medications in a safe and timely manner and in accordance with established regulations and guidelines . 1. Review of a community reported complaint submitted to the Rhode Island Department of Health on 4/14/2025 alleged that Resident ID #1 was not receiving his/her pain medications from staff even though s/he complained of an 8 out of 10 pain level. Record review revealed Resident ID #1 was admitted to the facility in December of 2021 with diagnoses including, but not limited to, cellulitis (a bacterial skin infection) of left lower limb, acute respiratory failure and emphysema (a chronic lung disease that damage the lungs' air sacs making the breathing difficult). Record review of his/her significant change status Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. Review of the resident's care plan dated 2/19/2025, revealed s/he is receiving Hospice care with interventions to administer pain medications, monitor and record its effectiveness, document, assess for pain and ensure a comfortable end of life. Additional record review of the care plan dated 2/19/2025 revealed s/he is receiving psychotropic drugs related to anxiety and panic, with fear and distressing delusions. Record review of the physician's orders revealed the following medications: - MS Contin/ morphine (a medication prescribed to treat severe pain) 15 Milligram (MG) three time a day. - Morphine concentrate 0.75 Milliliters (ML) every 3 hours as needed (PRN) for pain. Record review of the nursing progress notes dated 4/11/2025 revealed the following: - 2:47 PM- the resident requested pain medication every hour on the 7:00 AM to 3:00 PM shift. - 6:03 PM- Resident with complaints of uncontrolled pain. In addition to scheduled medication the resident requests as needed medications, approximately every hour. - 6:47 PM- the resident was sent to the hospital at 4:05 PM for an evaluation of his/her pain. The note also indicated that the resident had stated to the facility nurses and hospice nurses that s/he did not receive his/her PRN medications. Record review of the April 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident received any PRN pain medication after 9:54 AM, when the record reveals that s/he was complaining of pain approximately every hour. During a surveyor interview on 3/14/2025 at approximately 11:00 AM with Licensed Practical Nurse (LPN), Staff A, she revealed that the resident was transferred to the hospital on 4/11/2025 at 4:00 PM because the facility was unable to manage his/her pain. Additionally, Staff A indicated that the resident was administered his/her PRN Morphine concentrate at approximately 10:00 AM. Staff A indicated she did not administer any additional PRN pain medication during her shift. During a surveyor interview on 4/14/2025 at 11:18 AM with Registered Nurse, Staff B, she acknowledged the physician's PRN order for Morphine concentrate. When asked why the PRN Morphine concentrate was not administered to the resident after 1:00 PM or prior to the resident being transported to an acute care hospital she stated, we couldn't manage [his/her] pain. During a surveyor interview on 4/14/2025 at 2:17 PM with the Nurse Practitioner, she revealed that she was not aware that the PRN Morphine concentrate was not administered to the resident before his/her transfer to the hospital. During a surveyor interview on 4/14/2025 at 2:22 PM with the Assistant Director of Nursing, she indicated that the resident was doing well in the morning, but s/he started to become agitated around 1:30 to 2:00 PM because s/he believed his/her medications were not being administered to him/her. Additionally, she was unable to provide evidence that the PRN Morphine concentrate was administered before the resident's transfer to an acute care hospital. 2. Review of an additional community reported complaint submitted to the Rhode Island Department of Health on 4/17/2025 alleged multiple concerns which included the above-mentioned issues but also that the resident was having issues with his/her air mattress (a medical-grade support surface that uses alternating air pressure or low air loss technology to reduce the risk of pressure injuries). Record review of the physician's orders failed to reveal evidence of an order for the use of an air mattress, including the settings and specifications that the mattress should be set to. Record review of a nursing progress note dated 4/8/2025 authored by LPN, Staff C, indicated that the Hospice team was contacted to request a new air mattress due to the intermittent beeping from the bed. During a surveyor observation on 4/18/2025 at 10:40 AM in presence of the ADNS, there was an air mattress in the resident's room. During a surveyor interview following the above observation on 4/18/2025 at approximately 11:00 AM with the ADNS, she acknowledged that the resident had an air mattress before his/her transfer to the hospital. Additionally, she acknowledged that there was no evidence of a physician's order with settings or specifications for the air mattress.

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality for 2 of 3 residents reviewed for physician's orders, Resident ID #s 1 and 2. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 10/7/2024 alleges that the resident's .calves were often banged up from bad transfers . 1. Record review revealed Resident ID #1 was admitted to the facility in January of 2023 with diagnoses including, but are not limited to, malnutrition, left upper arm, left ribs, and left upper leg fractures. Record review revealed a physician's order dated 6/30/2024 to complete a weekly skin evaluation and document the findings under observations. Record review of the July, August and September 2024 Medication Administration Records revealed the weekly skin evaluations were signed off as completed on the following dates: -7/5/2024 -7/12/2024 -7/26/2024 -8/2/2024 -8/9/2024 -8/16/2024 -9/6/2024 -9/13/2024 Record review of the Weekly Skin Evaluation Observations failed to reveal evidence that the weekly skin assessments were completed and documented for the on the above-mentioned dates, although they were signed off as being completed. 2. Record review revealed Resident ID #2 was admitted to the facility in October of 2022 with diagnoses including, but is not limited to, dementia, difficulty in walking and syncope (fainting). Record review revealed a physician's order dated 6/30/2024, to complete a weekly skin evaluation and document the findings under observations. Record review of the September 2024 Medication Administration Record revealed the weekly skin evaluations were signed off as completed on 9/10/2024 and 9/17/2024. Record review of the Weekly Skin Evaluation Observations failed to reveal evidence that the weekly skin assessments were completed and documented on 9/10/2024 and 9/17/2024, although they were signed off as being completed. During a surveyor interview on 10/9/2024 at approximately 3:41 PM with the Director of Nursing Services, she was unable to provide evidence that weekly skin assessments were completed per the physician's order.

Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skills sets to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment as required for 2 of 5 staff reviewed, Nursing Assistants (NA), Staff A and B. Findings are as follows: Record review of the facility assessment states staff training and education on mechanical lifts will be completed on orientation and annually. Record review failed to reveal evidence of competencies and skills sets for safe patient handling on orientation relative to transfers with a mechanical lift for the following staff: - NA, Staff A with a hire date of 8/21/2024 - NA, Staff B with a hire date of 8/30/2024 During a surveyor interview on 10/10/2024 at 1:20 PM with the Regional Nurse, she was unable to provide evidence that the mechanical lift competencies were completed with Staff A and B prior to providing care to the resident's.

Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nursing assistant (NA), at least once every 12 months, for 5 of 5 NA personnel records reviewed, Staff G, H, I, J, and K. Findings are as follows: Record review of the personnel files failed to reveal evidence that an annual performance evaluation was completed for the following NAs: -Staff G, - Date of hire 2/12/2005 -Staff H, - Date of hire 1/16/2023 -Staff I, - Date of hire 3/21/2022 -Staff J, -Date of hire 9/5/2017 -Staff K, - Date of hire 8/22/2016 During a surveyor interview with the Director of Nursing Services on 7/10/2024 at 2:09 PM she was unable to provide evidence of a completed performance evaluation within the last 12 months for the above-mentioned employees.

39496 Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections due to utilizing Personal Protective Equipment (PPE) according to professional standards and properly disinfecting hands to prevent the transmission of potential pathogens (bacteria, virus or microorganisms that may cause disease) prior to providing care for 1 of 1 resident observed for Activities of Daily Living, Resident ID #281. Additionally, the facility failed to utilize appropriate precautions to reduce the transmission of multidrug-resistant organisms [MDROs-bacteria that are resistant to two or more classes of antibiotics] for 2 of 4 residents reviewed, Resident ID #s 32 and 48. Furthermore, the facility failed to handle, store, and transport linens appropriately, utilizing standard precautions. Findings are as follows: The Centers for Disease Control and Prevention (CDC) publication titled Guideline for Hand Hygiene in Health-Care Settings states in part, The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care setting .Recommendations .These recommendations are designed to improve hand hygiene practices of HCWs and to reduce transmission of pathogenic microorganisms to patients and personnel in health care settings .Decontaminate hands before having direct contact with patients .Decontaminate hands after contact with body fluids or excretions .Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient . 1. During a surveyor observation on 7/10/2024 at 10:22 AM revealed Nursing Assistant (NA), Staff B entering Resident ID #281's room with towels in preparation to perform personal care. Additionally, Staff B was observed removing the basin from the commode and entering the bathroom without wearing gloves. Immediately after, Staff B was observed exiting the restroom with the basin and placing it inside the commode, failing to perform hand hygiene. Staff B began to prepare clean towels to wash the resident with, until the surveyor intervened. During a surveyor interview on 7/10/2024 at 10:25 AM with Staff B, she acknowledged that she was not wearing gloves while transferring the basin containing urine. Additionally, she stated she should have performed hand hygiene prior to continuing to provide personal care to Resident ID #281. During a surveyor interview on 7/10/2024 at 3:28 PM with the Director of Nursing Services, she revealed that she would have expected for Staff B to follow basic infection control practices by using gloves and performing hand hygiene. 2. Review of the CDC guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug resistant Organisms (MDROs) last updated 7/12/2022 revealed in part, .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions [gown and glove upon entering the room] do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization [the bacteria is living on or in the body not causing symptoms but the bacteria can be spread to others] as well as for residents with MDRO infection or colonization .Summary of Personal Protective Equipment (PPE) Use and Room Restriction When Caring for Residents in Nursing Homes .Enhanced Barrier Precautions .All residents with any of the following .Infection or colonization with an MDRO when Contact Precautions do not otherwise apply . Review of the CDC guidance titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) updated on 7/12/2022 reveals in part, .Enhanced Barrier Precautions All residents with any of the following .Wounds .During high-contact resident care activities .Dressing, Bathing .Transferring .Providing hygiene .Changing briefs or assisting with toileting .Gloves and gown prior to the high-contact care activity . Review of the facility policy titled, Guidelines for management of MDROs revealed in part, Contact Precautions- In addition to standard precautions, contact precautions or the equivalent used with specific persons known or suspected to be infected or colonized with epidemiologically important micro-organisms that can be transmitted by direct contact with the person or indirect contact with environmental surfaces or equipment. Contact precautions include proper patient placement, proper use of PPE, and proper environmental measures as recommended in .CDC Isolation Guidelines .Enhanced Barrier It has been determined by the CDC that focusing on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, which can persist for long periods of time .and result in the silent spread of MDROs. Enhanced barrier precautions fall between Standard and Contact Precautions and requires gown and gloves for all residents with infection or colonization with an MDRO when contact precautions do not apply and for those with wounds or indwelling medical devices, regardless of MDRO colonization status during specific high contact care activities that have been found to increase the risk for MDRO transmission . a) During a surveyor observation on 7/9/2024 at 12:12 PM revealed the Housekeeper, Staff N, in Resident ID #48's room, who was on Contact Precautions, sweeping the resident's floor without wearing any gloves or additional PPE. Staff N assisted Resident ID #128, who was the roommate of Resident ID #48 with his/her telephone, dialing, putting the telephone to her ear, touching the resident's napkins, walker, and bedside table without any PPE. Staff N was then observed exiting the resident's room, without performing hand hygiene, and walked down the hallway to the housekeeping closet, retrieved a dustpan and brush, returned to the resident's room to sweep the debris from the floor. Staff N exited the room without performing hand hygiene, and then entered the resident lounge area and stood in the doorway. During a surveyor interview immediately following the above observation, Staff N acknowledged she touched all the items mentioned above, she was unable to explain why she did not wear gloves or additional PPE while she was in a contact precaution room. After the surveyor asked her if she wanted to wash her hands, Staff N entered another resident's room where she washed her hands in their sink. b) Record review revealed Resident ID #56 was admitted to the facility in March of 2022 and has diagnoses including but not limited to, unspecified open wound of right toe. Record review revealed a progress note dated 7/2/2024 at 1:47 PM which states in part, Assessed and treated by wound NP [Nurse Practitioner] Right toe trauma .raised 100% eschar [dead tissue] .excoriation [abrasion] between toes .Betadine [topical antiseptic] daily to site. Web calcium Alginate [a type of dressing] in between toes, no cover dressing . During a surveyor observation on 7/11/2024 at 11:57 AM, revealed Registered Nurse, Staff O, performing a dressing change on Resident ID # 56. He utilized the bed side table of Resident ID #32 (the roommate) to set up the items needed for the dressing change. During the dressing change, Staff O was noted to touch Resident ID #56's foot and wound with his gloved hands and then touch the bedside table with the same soiled gloves. When the dressing was completed Staff O returned Resident ID #32's bedside table to his/her bedside without cleaning it. Record review revealed Resident ID #32 was admitted to the facility in July of 2017 and has diagnoses including but not limited to, displaced fracture of greater trochanter of left femur and open wound of left elbow. Record review of a care plan dated 3/29/2024 revealed s/he was on Enhanced Barrier Precautions related to a surgical site. During an interview immediately following the above observation, Staff O acknowledged that Resident ID #32 was on Enhanced Barrier Precautions. He further acknowledged that he did not clean Resident ID #32's bedside table after utilizing it to change the wound dressing for Resident ID #56. 3. During a surveyor observation of the laundry room on 7/11/2024 at 12:30 PM, in the presence of the Director of Nursing, revealed the drying area with two large gas dryers and approximately three to four feet directly across from the dryers, a dumbwaiter [a passageway between floors used to move soiled laundry from upper floors to the laundry room]. During an interview with the laundry staff, Staff P, s/he revealed all the facility's soiled laundry is received from the dumbwaiter in bags and either carried manually or placed in a laundry bin and rolled through the drying/folding room to the soiled laundry room approximately 5-6 feet away. Additionally, s/he revealed that s/he doesn't wear a gown when carrying or sorting the laundry unless it appears visibly soiled. Review of the dryer lint removal schedule revealed the lint filters are emptied four times daily. The documentation revealed the following: -The June 2024 documentation revealed the lint trap was not signed off as emptied on 6/1, 6/3, 6/7, 6/9, 6/10, 6/15, 6/16, 6/17, 6/21, 6/23, 6/24, 6/25, 6/29, and 6/30. The July 2024 lint removal schedule revealed the lint filters were not signed off as emptied on 7/1, 7/4, 7/5, 7/7, and 7/8. During an interview with the Maintenance Director on 7/11/2024 at approximately 1:00 PM, he was unable to provide evidence that the lint filters were checked or emptied on the above days. 43987

Based on record review and staff interview, it has been determined that the facility failed to implement and maintain an effective, comprehensive, data-driven, Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. Findings are as follows: Review of the QAPI binders on 7/11/2024 at 10:00 AM in the presence of the facility Administrator revealed the following: Review of the August 2023, December 2023, and March 2024 QAPI meeting revealed evidence of QAPI plans created for areas identified as concerns. However, there was no evidence of implementation or maintenance of the plan, including tracking and measuring performance, and establishing goals and thresholds for performance measurement. Review of the June 2024 QAPI meeting revealed evidence of identifying concerns which would aid in the establishment of QAPI plans. However, it failed to reveal completed QAPI plans related to the identified concerns, or evidence of implementation or maintenance of the plan, including tracking, measuring performance, and establishing goals and thresholds for performance measurement. During a surveyor interview on 7/11/2024 at 11:30 AM, with the facility Administrator he was unable to provide evidence that the facility implemented and maintained an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to prepare, store, and distribute food according to professional standards of food service safety, relative to the main kitchen and 2 of 3 nourishment areas observed. Findings are as follows: 1.Review of the Rhode Island Food Code, 2018 Edition, section ,d+[DATE].17 states in part, .(B) .refrigerated, ready-to-eat time/temperature control for safety food .shall be clearly marked, at the time the original container is opened in a food establishment .and: (1) the day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date . a)During a surveyor observation in the presence of the Food Service Director (FSD) on [DATE] at approximately 7:45 AM during the initial tour of the kitchen, of a large refrigerator located in the main cooking space, revealed the following: A pan of what appeared to be pasta salad covered in plastic wrap, not labeled, or dated. b)During a surveyor observation in the presence of the FSD on [DATE] at approximately 7:45 AM during the initial tour of the kitchen, of a small refrigerator located in the main cooking space, revealed the following: A pan containing 2 hard-boiled eggs covered in plastic wrap, not labeled, or dated. During a surveyor interview at the time of the above observations, the FSD could not provide evidence that the above food items were clearly marked with the contents and the date. c)During a surveyor observation on [DATE] at approximately 1:30 PM of a kitchenette in the upstairs lounge, revealed the following: 9 Dannon light and fit 4-ounce yogurt cups which expired on [DATE]. During a surveyor interview with Registered Nurse, Staff F, she acknowledged the yogurt was expired and should be thrown away. d) During a surveyor observation on [DATE] at approximately 1:45 PM of a kitchenette in the downstairs lounge, revealed the following: 13 Dannon light and fit 4-ounce yogurt cups which expired on [DATE]. A clear 4-quart container with a green lid containing a granulated brown substance that wasn't labeled or dated. The container had a white plastic spoon inside resting directly on the contents of the container. During a surveyor interview on [DATE] at 2:00 PM with the FSD, he acknowledged the yogurts were expired. He also acknowledged that the 4-quart container should have been labeled and dated, and that the spoon should have not been stored in the container. 2. Record review of the Rhode Island Food Code 2018 edition, section ,d+[DATE].15 Package Integrity states in part, Food Packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants . During a surveyor observation in the presence of the FSD on [DATE] during the initial tour of the kitchen, of a freezer located in the room that you enter from the elevator, revealed the following: 10 Chicken patties in a metal pan dated ,d+[DATE] which was only half covered in plastic. A large, opened box containing an internal plastic bag with a large quantity of beef patties inside. The bag was not sealed, wide open, and not dated when opened. During a surveyor observation in the presence of the FSD on [DATE] during the initial tour of the kitchen, of a freezer located in the storage room, revealed the following: A large, opened box containing an internal plastic bag with a large quantity of cookie dough balls. The bag was not sealed, wide open, and not dated when opened. During a surveyor interview at the time of the above observations, the FSD was unable to provide evidence that the food packages were in good condition to protect the integrity of the contents. 3. Record review of the Rhode Island Food Code, 2018 Edition, section ,d+[DATE].11 states in part, .(B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under XXX,d+[DATE].15. ,d+[DATE].112, and ,d+[DATE].113 and achieving a UTENSIL surface temperature of 71 C (160 F) as measured by an irreversible registering temperature indicator . During a surveyor observation on [DATE] at 9:30 AM of the stationary rack high temperature dishwasher, in the presence of the FSD, the surveyor requested the use of a temperature sensitive label in the dishwasher to determine whether the required temperatures for sanitation have been reached. The FSD used a temperature sensitive label called ECOLAB. While running the load of dishes, the temperature gauge on the front of the dishwasher read ,d+[DATE] Fahrenheit (F) degrees during the wash cycle and 190 degrees during the rinse cycle. The temperature sensitive label, which was placed on a plate, did not react, and turn black( a square on the label is supposed to turn black when the temperature has been achieved.) The fact that it didn't turn black indicated that the proper temperature had not been achieved for sanitization. During an interview with the FSD immediately following the above observation the surveyor expressed concern regarding the label not reacting and therefore not reaching the proper temperature to sanitizing dishes. He acknowledged that the temperature sensitive strip did not react and turn black. He said the gauge on the dishwasher is fine but sometimes the dishwasher needs a break and that we should retry in 10 minutes. He said that he tests the dishwasher with the temperature sensitive labels once per week, but could not provide evidence, stating that he throws them away and doesn't document the results. During a surveyor observation approximately 10 minutes later, the FSD used two types of temperature sensitive labels (an Ecolab and a 3-temp Thermolabel) placed them on plates and again they did not react and turn black indicating the proper temperature had not been achieved for sanitation. The surveyor questioned whether the temperature gauge on the outside of the dishwasher is broken, because the labels are not reacting indicating that the proper temperature had not been achieved for sanitation. He revealed that he felt that the plates were too heavy, and that might be why the labels were not reacting. He stated that he was going to try thin metal plate covers that they use to transport food plates. During a surveyor observation the FSD placed the metal plate covers into the dishwasher with the temperature sensitive labels attached, they reacted with the square turning black at 160 Fahrenheit on the ECOLAB and 160 F and170 F on the 3 temp thermolabel. At that point the Food Service Director said that the labels are working. During a surveyor observation on [DATE] at 10:06 AM the FSD placed a large plastic tray into the dishwasher, the temperature sensitive labels again did not react indicating that the proper temperature had not been achieved for sanitation. During a surveyor interview after the above observation, the surveyor asked the FSD what he plans to do, he revealed that they will get someone to look at the machine and use paper products for lunch. During a surveyor interview on [DATE] at 2:21 PM with the repairman from [company name redacted] he revealed that the dishwasher's thermostat was faulty, and that the thermostat connector was blocked so the machine would think the water reached the required temperature and shut the electrical off, preventing the wash tank to heat to the required temperature for sanitation. 4. Review of the Rhode Island Food Code, 2018 Edition, section ,d+[DATE].11 states in part, .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens . During a surveyor observation on [DATE] at 12:14 PM until 12:30 PM of the FSD, in the first-floor lounge, serving food onto plates from the steam table. He was not wearing a beard restraint. During a surveyor interview on [DATE] at 12:44 PM with the FSD, he acknowledged that he should have been wearing a beard covering while serving food onto plates from the steam table. 5.Record review of the Rhode Island Food Code, 2018 Edition, section ,d+[DATE].11 states in part, .the permit holder shall be the PERSON IN CHARGE or shall Designate a Person in charge and shall ensure that a PERSON IN CHARGE is present at the FOOD ESTABLISHMENT during all hours of operation . Record review of the Certified Food Safety Managers license for Dietary Cook, Staff M, with a date of hire of [DATE], revealed that his license expired on [DATE]. Record review of the dietary staffing schedule for [DATE], through [DATE], revealed that Staff M was the only cook, and there failed to be a staff member who had an active Certified Food Safety Managers license in the kitchen during all hours of operation on the following dates and times: [DATE], from 9:00 AM until 11:00 AM [DATE], from 4:00 PM until 7:00 PM [DATE], from 4:00 PM until 7:00 PM [DATE], from 1:30 PM until 7:00 PM [DATE], from 4:00 PM until 7:00 PM [DATE], from 4:00 PM until 7:00 PM [DATE], from 2:00 PM until 7:00 PM [DATE], from 4:00PM until 7:00 PM [DATE], from 1:30 PM until 7:00 PM [DATE], from 5:30 AM until 11:00 AM During a surveyor interview on [DATE] at 4:36 PM with the facility Administrator he could not provide evidence that there was a staff member who had an active Certified Food Safety Managers license in the kitchen during all hours of operation on the above dates and times. 43987

Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that nourishing snacks were offered to residents at bedtime, for 5 of 9 residents interviewed for bedtime snacks, Resident ID #s 2, 3, 5, 18, and 36. Findings are as follows: According to the State Operations Manual for Long Term Care regarding Frequency of Meals, it states in part, There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime . During the resident council meeting held on 7/10/2024 at 11:00 AM, 5 out of 9 resident council members who were in attendance indicated that bedtime snacks are not offered. Additionally, they indicated they would enjoy being offered bedtime snacks. During a surveyor interview on 7/11/2024 at 9:45 AM with the Administrator, he indicated that they start serving breakfast at 8:00 AM and supper starts at approximately 5:00 PM. Additionally, he acknowledged that there are more than 14 hours between the evening meal and the breakfast meal the following day. Lastly, the Administrator was unable to provide evidence that all residents were offered or received bedtime snacks every night.

Based on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or protein levels for 4 of 10 residents reviewed for nutrition, Resident ID#s 12, 65, 72, and 74. Findings are as follows: Record review of the State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, revised on 2/3/2023, reveals a weight loss of 5% in 1 month, 7.5% in 3 months, and 10% in 6 months is significant weight loss. Additionally, greater than 5% in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months is severe weight loss. Review of the facility's policy and procedure undated and untitled, provided to surveyors on 5/22/2023, states in part, .Goal Resident will not have a significant weight loss. Policy and Procedure: 1. Resident will be weighted on admission and at least monthly. 2. Provider and /family/responsible party will be notified re [relative to] significant weight loss. 3. Dietician consult on admission, quarterly and as indicates. 4. IDT [Interdisciplinary Team] will implement interventions and will adjust according to resident preferences . Although, the above policy and procedure indicates a provider and family/responsibly party will be notified relative to significant weight loss, the policy failed to specify a definition of significant weight loss. Additionally, the policy failed to specify a procedure indicating the steps to take when a weight discrepancy is noted. 1. Record review for Resident ID #12 revealed s/he was admitted to the facility in September of 2022 with diagnoses to include, but not limited to, dementia, anemia (a lower-than-normal amount of red blood cells in blood level), hypothyroidism (thyroid grand does not produce enough hormones), protein-calorie malnutrition, and dysphagia (difficulty swallowing). Review of the Care Area Assessment (CAA, a process that provides guidance on how to focus on key issues identified during a comprehensive assessment) summary dated 9/21/2022 revealed the resident was triggered for nutrition, this CAA was due to receiving a mechanically altered diet and having an order for aspiration precaution. This CAA indicates a care plan for nutrition would be developed. Record review failed to reveal a care plan was developed as indicated according to the above CAA summary. Further record review revealed the resident had a physician's order dated 9/29/2022 for weekly weights to be obtained on Thursdays. Review of the weight records for April and May 2023 failed to reveal evidence the resident's weights were obtained as ordered on the following days; -4/13/023 -4/27/2023 -5/4/2023 -5/11/2023 Record review revealed the resident's weight was documented as 129.2 - 137.1 pound (lbs) between 12/15/2022 and 3/30/2023. Further record review revealed the resident's weight was 130.4 lbs on 4/6/2023 and 105.8 lbs on 4/20/2023, which indicates a 24.6 lbs (18.87 %) weight loss in 2 weeks and lost (28.6 lbs or 21.34 % in approximately 4 months). Additionally, the record revealed the resident's weight was 105 lbs on 5/10/2023, which indicated a 25.4 lbs (19.48 %) weight loss in approximately 1 month and lost (29 lbs or 21.64 %) in approximately 5 months. Record review failed to reveal evidence that the provider and /family/responsible party were notified or that the dietician was consulted when the resident experienced a severe weight loss. During a surveyor interview with the Director of Nursing Services (DNS) on 5/17/2023 at 11:17 AM, she revealed that she was unaware of the above-mentioned weight loss. Additionally, she was unable to provide evidence any steps were taken to verify if the weights were accurate or that a care plan for nutrition was developed to address the nutritional status as indicated in the CAA. Additionally, she was unable to provide evidence that the resident's provider, family/responsible party or the dietitian were notified as per the facility policy. During an interview with the Minimum Data Set Coordinator, on 5/17/2023 at 11:28 AM, she revealed that the dietitian assesses the resident's nutritional status and if it is triggered on the CAA, a care plan for nutrition will be developed by the dietitian. Additionally, she was unable to provide evidence that a care plan for nutrition was developed or implemented for the resident when it was triggered on the CAA on 9/21/2022. During a surveyor interview with the resident's provider, Nurse Practitioner, Staff F, on 5/17/2023 at 11:30 AM, she revealed that she was unaware of the resident's severe weight loss, until the DNS informed her a few minutes prior to this interview. She further revealed that she would expect staff to obtain the resident's weight every week as ordered. Staff F then revealed that she would expect staff to notify her if a resident has a significant weight gain or loss. Additionally she indicated that a significant weight gain or loss would be when a resident gained or lost 3 lbs. or more from their previous weight. Staff F further revealed that she would expect residents with weight changes of 3lbs. or more lbs from their previous reading to be reweighed. During a telephone interview with Dietitian, Staff G, on 5/17/2023 at 1:02 PM, she revealed that she was unaware of the above-mentioned weight loss. She further revealed that she is new to the facility and was not aware that the resident did not have a plan of care for nutrition. Additionally she indicated that she is not familiar with the facility's policy. During a surveyor interview with Licensed Practical Nurse, Staff H, in present of the Corporate Nurse, Staff I, on 5/18/2023 at 12:56 PM, she revealed that she monitors all resident weights for weight loss and/or discrepancies. She further revealed that she runs the weight report once a month and the last time she ran the weight report was for the month of April, 2023. Additionally, she revealed that she was not informed of the above-mentioned weight loss on 4/20/2023 and 5/10/2023 and would expect staff to inform her when a resident experiences a significant weight loss. 2. Record review for Resident ID #65 revealed s/he was admitted to the facility in February of 2023 with diagnoses to include, but not limited to, dementia, gastro-esophageal reflux disease (acid reflux) and severe protein-calorie malnutrition. Record review revealed the resident's weight was 92.2 lbs on 4/18/2023 and 85 lbs on 5/9/2023, which indicates a 7.2 lbs (7.81%) weight loss, in 3 weeks. Further record review revealed the resident's weight was 85.6 lbs on 5/16/2023, which indicates a 6.6 lbs weight loss (7.16 %), in approximately 1 month. During a surveyor interview with the DNS on 5/18/2023 at 3:45 PM, she revealed she was unaware of the above-mentioned weight loss. The DNS was unable to provide evidence that the resident's provider, family/responsible party and/or dietitian were notified as per the facility policy. Additionally, the DNS was unable to provide evidence that a new intervention was implemented to the plan of care to address the resident's severe weight loss. 3. Record review for Resident ID #72 revealed s/he was admitted to the facility in January of 2022 with diagnoses to include, but not limited to, dementia and anemia. Record review revealed the resident has a physician's order dated 9/19/2022 to administer Promod Protein (protein supplement) liquid, 30 milliliters by mouth once a day between 7:00 AM - 11:00 AM. Record review of the Medication Administration Records for April and May, 2023 revealed that the Promod protein supplement had not been administered as ordered since 4/18/2023 (approximately 4 weeks). Review of the Quarterly Nutritional Note dated 10/31/2022 revealed 1 Promod protein supplement provides approximately 18 grams of protein/day. The note further revealed that the resident's protein levels (Albumin and Prealbumin levels, both serum proteins use to evaluate protein malnutrition and overall nutrition health) have been running low with some improvement. Review of the Quarterly Nutritional Note dated 5/1/2023 revealed to continue the supplement as ordered. During a surveyor interview with Medication Technician, Staff C, on 5/16/2023 at 8:30 AM, she revealed that the resident had not been receiving Promod protein supplement because it is unavailable. Review of the record revealed the resident's albumin level was 3.5 g/dl (grams per deciliter) and prealbumin level was 14.8 g/dl on 12/8/2023 and decreased to 3.1 g/dl and prealbumin level was 13.8 g/dl on 5/17/2023 (normal range for albumin is 3.5 - 5 g/dL. Low albumin levels can lead to edema, fatigue, and weakness. The normal range for prealbumin is 15 - 36 mg/dL). During a surveyor interview with the DNS on 5/16/2023 at 4:48 PM, she was unable to provide evidence that the resident had been receiving Promod protein supplement as ordered since 4/18/2023. 4. Record review revealed Resident ID #74 was admitted to the facility in December of 2022 with diagnoses that include but are not limited to, dementia and vitamin deficiency. Record review of the care plan, last reviewed on 5/9/2023 revealed that s/he is at risk for an alteration in nutritional status due to receiving a therapeutic diet. Record review revealed a physician's order with a start date of 3/25/2023 which indicates the resident's weight is to be obtained weekly. Record review of the resident's weekly weights from 4/7/2023 through 5/12/2023 revealed the following: - 4/7/2023, weight 133 lbs. - 4/14/2023, weight 132 lbs. - 4/21/2023, weight 133 lbs. - 4/28/2023, weight 136.6 lbs. - 5/12/2023, weight 124.6 lbs Indicating the resident experienced an 8.4 lbs weight loss from 4/7/2023 to 5/12/2023 6.32% weight loss in 5 weeks, and a weight loss of 7.4 lbs. between 4/14/2023 and 5/12/2023 which is a 5.61 % weight loss in approximately 1 month. Additional record review failed to reveal evidence that the provider/family/responsible party were notified or that the dietician was consulted when the resident experienced a severe weight loss. During a surveyor telephone interview with Staff G on 5/16/2023 at 5:06 PM, she indicated that she was not aware of the resident's severe weight loss and would have expected staff to obtain a reweigh if the resident had a loss or gain of 3 lbs. or more from the previous weight. During a surveyor interview with the DNS on 5/17/2023 at 9:07 AM, she was unable to provide evidence that the resident was reweighed to verify the weight discrepancy until it was brought to the attention of the facility by the surveyor. Additionally, she was unable to provide evidence that the Dietitian was notified of the resident's documented weight on 5/12/2023. 46671

Based on record review and resident and staff interview it has been determined that the facility failed to ensure that its residents are kept free from significant medication errors for 1 of 4 residents reviewed for medication administration, Resident ID #3. Findings are as follows: Record review revealed the resident was admitted to the facility in May of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility Adverse Event Report stated in part, This resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On Friday afternoon (10/7/22), [S/he] received the incorrect eye solution and was instead given Covid Reagent drops [liquid reagent used as a preservative that triggers a chemical reaction to determine if the test is positive or negative] in both eyes. Resident experienced immediate burning of the eyes; subsequently, the nurse verified the eye drops were incorrect . Review of the resident's progress notes revealed the following: 10/7/2022 at 1:19 PM, Residents bilateral eyes burning due to incorrect eye solution being administered this am. Resident's eyes are being flushed with saline and lubricant eye drops in effort to relieve discomfort . 10/7/2022 at 7:52 PM, .[S/he] is seen today for eye pain after sodium azide [ingredient in Covid Reagent Drops] administered to bilateral eyes. Reports burning, watering beginning minutes ago upon administration, initially unsure of vision changes . 10/7/2022 at 11:06 PM, .Resident c/o [complained of] both eyes pain/discomfort and acetaminophen 1,000mg [milligrams] admin [administered] w/ GE [with good effect]. Eye drops admin a/o [as ordered] . 10/9/2022 at 1:42 PM, Res [resident] c/o slight burning to eyes upon rising this am and stated that it feels gritty both eyes flushed, and res reported relief, eyes remains red/puffy . During a surveyor interview with the resident on 10/12/2022 at 10:32 AM, s/he revealed that s/he was administered the wrong solution for his/her eyes. S/he further revealed that it caused pain and irritation when administered [MEDICATION(S)] for a few days. During a surveyor interview with Registered Nurse, Staff A on 10/12/2022 at 11:43 AM, she revealed she administered the Covid reagent solution to Resident ID #3 on 10/7/2022 due to the solution being in the box labeled [MEDICATION(S)] Eye drops. She further indicated the reagent solution is often stored in the same drawer on the medication cart as eye drops and the bottles look similar. She stated the resident screamed when the solution was put into his/her eyes and that is how she was aware of the error. During a surveyor interview with the facility Optometrist on 10/13/2022 at 9:55 AM she revealed that she examined the resident's eyes on 10/7/2022 and his/her eyes were red and swollen due to a chemical burn from the Covid reagent solution. She further revealed the resident was in a lot of pain. During a surveyor interview with the Administrator on 10/12/2022 at 11:10 AM, she acknowledged the Covid reagent drops were administered to the resident instead of the [MEDICATION(S)] eye drops.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to protect the resident's right to be free from sexual abuse for 2 of 4 residents reviewed, Resident ID's #2 and 3. Findings are as follows: Record review of facility reported complaint that was submitted to the Department of Health on 6/11/2022 indicated a Licensed Practical Nurse (LPN), Staff A, witnessed Resident ID #1, inappropriately touching his/her roommate, Resident ID #2. Review of the employee training titled: Abuse Neglect and Exploitation Defines sexual abuse as the non-consensual sexual contact of any kind with a resident. Sexual contact with any person incapable of giving consent is also considered sexual abuse. This includes, but is not limited to, unwanted touching, all types of sexual assault or battery and sexually explicit photographing. 1. Review of the record for Resident ID #1, revealed s/he was admitted to the facility in March of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2/15, indicating severe cognitive impairment. Record review of Resident ID #2 revealed s/he was admitted to the facility in January of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 8/15, indicating moderate cognitive impairment. Surveyor interview on 6/13/2022 at 3:21 PM, with Staff Nurse A, relative to the progress note, she wrote dated 6/11/2022 at 10:31 PM which states. Resident displaying out of ordinary Hypersexual behaviors. 15 mins check Initiated by Nursing and Referral made to Geri psych. Daughter . made aware, Dr and DON [Director of Nursing] updated. When ambulance arrived at approximately 8PM, writer went to Resident's room and found him/her inappropriately touching roommate . Staff A informed the surveyor that when she came to work on 6/11/2022 for the second shift, she was informed in report by the first shift nurse (Staff C) that Resident ID #1 had been having inappropriate behavior towards his/her roommate during the 7 AM to 3 PM shift. She stated the resident was put on 15-minute safety checks and kept at the nurses' station for the dinner meal to keep him/her separate from Resident ID #2. Additionally, she informed the surveyor that when she went to pass medications, the CNA's apparently returned the resident to his/her room and put him/her to bed without her knowledge. Staff A stated that at approximately 7:00 PM, CNA, Staff E reported to her, that the resident ID #1 was reaching out of his/her bed and rubbing the foot of Resident ID #2. She stated she called the DON and was told to send the patient for a Geri psych evaluation. When the medical transport arrived at approximately 8:00 PM, she observed Resident ID #1, standing over Resident ID #2, with his hands on the bed. During a surveyor's interview on 6/14/2022 at 9:43 AM with Staff Nurse C, who had worked the first shift on 6/11/2022, she stated that during her shift Resident ID #1 had exposed his/her genitals to Resident ID #2. She further stated that she witnessed Resident ID #1 walking up to Resident ID #2 and making suggestive comments. She heard Resident ID #2 saying, get away and putting his/her hands on his/her head appearing anguished. She stated she reported this incident to the DON. Surveyor interview on 6/14/2022 at 9:33 AM with CNA Staff E who worked 7 AM to 7 PM on 6/11/2022, stated she witnessed Resident ID #1 rubbing resident ID #2's leg while in bed. She observed Resident ID #2, who appeared nervous and like s/he did not feel well. During a surveyor interview with Resident ID #1's daughter on 6/14/2022 at 12:00 PM, she reported visiting facility on 6/11/2022 and being told her parent had been sexually inappropriate with Resident ID #2 on three occasions during that day. She stated that she was called later in the evening, by Staff Nurse A, and told her parent was witnessed performing oral sex on Resident ID #2. Resident daughter further stated she was upset that Resident ID #1 was not watched better and was involved in a fourth incident on that day. During a surveyor interview with the DON on 6/14/2022 at 11:16 AM, she was unable to provide evidence that on 6/11/2022 during the first shift when the resident was noted to be exposing him/herself and making advances towards his/her roommate, that the facility implemented any measures to keep Resident ID #2 safe. Additionally, she was unable to produce evidence that the 15-minute safety checks, initiated on the second shift, were being conducted. Additionally, she could not explain why the CNA's returned the resident to his/her room when the nurse was monitoring him/her by keeping the resident at the nurse's desk. The DON was unable to produce evidence that Resident ID #2 was kept free from abuse. Review of the record for Resident ID #1, lacks any documentation from the first shift during which time it has been determined that the resident was displaying hypersexual behaviors and approaching his/her roommate, or that any interventions were implemented. 2. Record review for Resident ID #3, revealed s/he was admitted to the facility in May of 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] with a BIMS score of 11/15, indicating moderate cognitive impairment. The record revealed a progress note dated 6/2/2022 at 2:00 AM, by Staff Nurse B, an LPN, which read in part, .stayed in dining room for a while after dinner. CNA witnessed him/her grab [Resident ID #3's] breasts. CNA brought resident to room to diffuse situation . Surveyor interview with the nurse, Staff B on 6/14/2022 at 10:31 AM she stated, CNA, Staff F reported that Resident ID #1 grabbed Resident ID #3's breasts while seated in the dining room. She stated that she did not perform an assessment of Resident ID #3 when she was notified by the CNA of the incident. She stated she reported the incident to the DON and acknowledged that she did not notify the Department of Health. Surveyor interview with DON on 6/14/2022 at 11:16AM she stated that she was unaware of the above allegation until she reviewed the progress notes on 6/12/2022 after an additional incident with Resident ID # 1 when s/he was observed exhibiting hypersexual behaviors. She was unable to produce evidence that the facility implemented interventions to ensure residents are kept free from abuse.